Alternative names:(Enter all aliases, including maiden name, if applicable, in the section below.)

Gender:

Date of Birth:

SSN:

Phone (H):

(Work):

(Cell):

E-Mail Address:

Driver’s License:

Address:

Other cities of residence in Texas.

How long have you lived in Texas?

List other countries and/or States where you have lived.

If you have lived in Texas for less than 5 years, please list all previous addresses during those 5 years.

Where were you born?

Ethnicity:

Race:

Are you volunteering through the Junior League?

YESNO

Current Occupation:

Employer:

Business Address:

Length of employment:

Previous Employer:

Length of employment:

Reason for leaving:

Spouse’s name:

Spouse’s Occupation:

Spouse’s Employer:

Spouse’s Work Phone #:

Emergency Contact/Relationship:

Phone:

Your Educational History(Select last year completed)

Name of College or University Attended:

College Major:

College Minor:

Do you have any physical limitations that may prevent you from performing the volunteer job for which you are applying?

YESNO

If so, please explain

Are you able to lift and carry children up to 20 pounds?

YESNO

Do you have any children? If so, please list ages and sex of each

Have you had Chicken Pox?

YESNO

If so, when?

If you have had chicken pox, then you are fine to go into a Casa House.

If you are unsure if you have had chicken pox, you must have a titer test. If this proves that you are immune, you are fine to go into a house. If it proves that you are not immune, then you must be vaccinated and wait one month before entering the house.

If you have not had chicken pox, you must be vaccinated and wait one month before entering the house.

PLEASE ATTACH A PHOTO COPY OF YOUR DRIVER’S LISCENSE OR STATE-ISSUED I.D. TO THIS APPLICATION.

Applicant’s Signature:

Date:

References

Please list the names, email, and/or mailing address of four (4) non-family members who have known you for a minimum of 3 years that we may contact for references. In addition, we will need the name, email, and/or mailing address of one family member to also be used as a reference. There is no need for you to request letters from these individuals, however, you may wish to inform them to expect an email/ mailing from Casa de Esperanza.

Name:

Relationship to you:

How long have you known this person?

Address-1:

Address-2:

Phone Number (H):

(W):

E-Mail Address:

Confidentiality Statement

If selected to volunteer with Casa de Esperanza, I agree to maintain the confidentiality of all client, volunteer and donor information.

Signature of Applicant:

Date:

I understand that if my volunteer application is denied, I will be notified of this decision in writing. I also understand that if denied, the reason(s) for this decision are completely confidential and that Casa de Esperanza staff members are not permitted to discuss them with me. I also understand that the same policy applies to termination.

Signature of Applicant:

Date:

Casa de EsperanzaVolunteer Applicant Questionnaire

This form has been designed for all volunteer position applicants – even if you do not intend to volunteer directly with the children. All information provided by you will be used to determine how you might best assist the agency and the children and families we serve. Please be prepared to discuss any of the following questions during your personal interview.

Write a short statement about your interest in Casa de Esperanza and your reasons for offering your services.

Are you currently undergoing medical treatment or taking medication? If so, please describe.

What is your most recent volunteer experience?

Describe what you liked most about this previous volunteer experience.

Describe what you like least about this previous volunteer experience.

Have you ever worked or volunteered with children? If so, in what capacity and for how long?

Do you describe yourself as a non-drinker, occasional, moderate, or heavy drinker?

Have you had any previous contact with Casa de Esperanza, Child Protective Services, or any other child placing agency in any capacity, (i.e. volunteer, client, made a report, foster parent)? If so, please explain.

How would you define child abuse?

Has child abuse (as you defined it) had an impact/effect on your life? If so, please explain.

Will you have a problem working with HIV+ or chronically ill children?

YESNO

If yes, please explain.

Are there any behaviors or medical conditions you would have difficulty with?

Describe your current involvement in community activities, clubs, churches, etc.

How did you hear about our volunteer program?

Respond to the following statement, “I am effective working with young children because…

Respond to the following statement, “I might have problems working with young children because…

Please list hobbies and special interests:

Is there anything else about yourself that you would like for us to know?

By signing below, I am confirming that I have thoroughly reviewed and answered the above “Volunteer Applicant Questionnaire” with honesty and to the best of my ability.

Applicant’s Signature:

Date:

Volunteer Availability and Preference

Please check the areas where you would like to serve Casa de Esperanza

Direct Child Care Assistance

Administration/Support

Sorting Donations

Yard/Building Maintenance

Special Events/Fundraising

Special Projects

Foster Parenting

Annual Benefit

Young Professionals

Other

For your information, scheduled house volunteer times are generally available every day of the week as follows. (Afternoon and evening hours may be adjusted to match the needs of individual houses.)
Please select your preferred day and time:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

9:30 am – 12:30 pm

2:30 pm – 5:30 pm

5:30 pm – 8:30 pm

Additional Comments

Demographic Information

Applicant’s Name:

Date:

Casa de Esperanza de los Ninos, Inc., is a 501(c)(3) non-profit organization, which receives all funding from private sources. To assist us in identifying possible funding and volunteer recruitment sources, we ask that you complete the following section.

Employer:

Spouse’s Employer:

Does either employer support any philanthropy with funding, time, donations, etc?

YESNO

Does either employer sponsor an “Employer Matching Gifts Program?

YESNO

Church/Synagogue Affiliation:

Does your religious organization have a mission/outreach/giving program?

YESNO

Name of contact person or pastor:

Civic Club Affiliation(please specify you or your spouse)

Fraternal Organizations (please specify you or your spouse)

Social Organizations (please specify you or your spouse)

Professional Organizations (please specify you or your spouse)

Please send me invitations to social functions of Casa de Esperanza de los Ninos

Do not send me invitations to social functions

How did you learn about Casa de Esperanza? If it was through a friend, an employer, or a project with a group, please explain.

Certification, Release and Authorization Form

CERTIFICATION
I certify that all statements made by me, including in my application, questionnaire and interview are true, complete and correct to the best of my knowledge and belief, are made in good faith, and that I have withheld nothing that would, if disclosed, affect this application unfavorably.

I hereby give my permission in exchange for good and valuable consideration for Casa de Esperanza de los Niño’s, Inc. to obtain information relating to my criminal history record through criminal record agencies. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received.

GENERAL RELEASE OF LIABILITY

On behalf of myself and my heirs, executors and administrators, I hereby release, discharge, and forever hold harmless Casa de Esperanza, the Center and each of their agents, employees, representatives, and directors, from all liability, costs or damages resulting from the investigation of my background in connection with my application to become a volunteer. I agree not to sue Casa de Esperanza,or any of their agents, employees, representatives, or directors, for any claim or cause of action related to or based upon this investigation. If accepted as a volunteer, I hereby agree to abide by all rules and policies of Casa de Esperanza, as explained in the Volunteer Orientation Manual, including any amendments that may be made from time to time. I also agree to notify Casa de Esperanza, immediately in the event that I am indicted for a felony or crime of moral turpitude. I will be advised if a criminal match is reported on my criminal history investigation and Casa de Esperanza has no responsibility to clarify or resolve the matter on my behalf.

My signature indicates that I have read and fully understand the above consent and release.

Casa de Esperanza de los Ninos strives to break the cycle of child abuse and neglect for at-risk infants, children and their families by providing comprehensive residential and family support programs that transform people and communities.